Choosing a Leadership Style (Marquis & Huston, 2012)
Standard 12. Ethics
The nurse administrator integrates ethical provisions in all areas of practice.
Measurement Criteria
1. Incorporates Code of Ethics for Nurses with Interpretive Statements (ANA, 2015) to guide practice 2. Assures the preservation and protection of the autonomy, dignity, and rights of individuals
3. Maintains confidentiality within legal and regulatory parameters
4. Assures a process to identify and address ethical issues within nursing and the organization 5. Participates on multidisciplinary and interdisciplinary teams that address ethical risks, benefits, and
outcomes
6. Demonstrates a commitment to practicing self-care, managing stress, and connecting with self and others
Source: American Nurses Association. (2009). Nursing administration: Scope and standards of practice. Silver Spring, MD: Author.
Ethical Problem Solving and Decision Making
Some of the difficulty people have in making ethical decisions can be attributed to a lack of formal education about problem solving. Other individuals lack the thinking skills or risk taking needed to solve complex ethical problems. Still, other nurses erroneously use decision-making outcomes as the sole basis for
determining the quality of the decision making. Although decision makers should be able to identify desirable and undesirable outcomes, outcomes alone cannot be used to assess the quality of the problem solving.
Many variables affect outcome, and some of these are beyond the control or foresight of the problem solver. In fact, even the most ethical courses of action can have undesirable and unavoidable consequences.
Indeed, Ramos (2015) notes that care professionals must recognize that many outcomes are the result of our practice circumstance and should not be considered personal or professional failures. In addition, Ramos argues that while caregivers can “own” their feelings, they should not take personal responsibility for the shortcomings of the systems they work in and the impossibilities of practice. “Care givers can no more control every outcome than anyone else working within the system” (Ramos, 2015, p. 1).
Thus, the quality of ethical problem solving should be evaluated in terms of both outcome and the process used to make the decision. The best possible decisions stem from structured problem solving, adequate data collection, and examination of multiple alternatives—even if outcomes are poor.
If a structured approach to problem solving is used, data gathering is adequate, and multiple alternatives are analyzed, even with a poor outcome, the nurse should accept that the best possible decision was made at that time with the information and resources available.
In addition, Mortell (2012) suggests that some decision making by nurses reflects a theory–practice–ethics gap despite the moral obligation, nurses have to ensure theory and practice are integrated. For example, Mortell notes that noncompliance exists in hand hygiene among practitioners despite ongoing infection prevention education and training; easy access to facilities such as wash basins; antiseptic/alcohol hand gels that are convenient, effective, and skin- and user-friendly; and organizational recognition and support for clinicians in hand washing and hand gel practices. Thus, despite nurses having knowledge of best practices based on current research, they continue to fail to achieve the required and desired compliance in hand hygiene. Mortell concludes that more emphasis should be placed on clinicians’ moral and ethical obligations as part of training and orientation and that organizations must continue to emphasize the duty of care toward patients in nurses’ decision making.
LEARNING EXERCISE
4.4
A Nagging Uneasiness
Y
ou are a nurse on a pediatric unit. One of your patients is a 15-month-old girl with a diagnosis of failure to thrive. The mother says that the child is emotional, cries a lot, and does not like to be held. You have been taking care of the child for 2 days since her admission, and she has smiled and been receptive to being held by you. She has also eaten well. There is something about the child’s reaction to the mother’sboyfriend that bothers you. The child appears to draw away from him when he visits. The mother is very young and seems to be rather immature but appears to care for the child.
This is the second hospital admission for this child. Although you were not on duty for the first
admission 6 weeks ago, you check the records and see that the child was admitted with the same diagnosis.
While you are on duty today, the child’s father calls and inquires about her condition. He lives several hundred miles away and requests that the child be hospitalized until the weekend (it is Wednesday) so that he can “check things out.” He tells you that he believes the child is mistreated. He says he is also concerned about his ex-wife’s 4-year-old child from another marriage and is attempting to gain custody of that child in addition to his own child. From what little the father said, you are aware that the divorce was bitter and that the mother has full custody.
You talk with the physician at length. He says that after the last hospitalization, he requested that the community health agency and Child Protective Services call on the family. Their subsequent report to him was that the 4-year-old child appeared happy and well and that the 15-month-old child appeared clean, although somewhat underweight. There was no evidence to suggest child abuse. However, the community health agency plans to continue following the children. He says that the mother has been good about keeping doctor appointments and has kept the children’s immunizations up to date. The pediatrician proceeds to write an order for discharge. He says that although he also feels somewhat uneasy, continued hospitalization is not justified, and the state medical aid will not pay for additional days. He also says that he will follow up once again with Child Protective Services to make another visit.
When the mother and her boyfriend come to take the baby home, the baby clings to you and refuses to go to the boyfriend. She also seems reluctant to go to the mother. All during the discharge, you are extremely uneasy. When you see the car drive away, you feel very sad.
After returning to the unit, you talk with your supervisor, who listens carefully and questions you at length. Finally, she says, “It seems as if you have nothing concrete on which to act and are only
experiencing feelings. I think you would be risking a lot of trouble for yourself and the hospital if you acted rashly at this time. Accusing people with no evidence and making them go through a traumatic experience is something I would hesitate to do.”
You leave the supervisor’s office still troubled. She did not tell you that you must do nothing, but you believe that she would disapprove of further action on your part. The doctor also felt strongly that there was no reason to do more than was already being done. The child will be followed by community health nurses.
Perhaps the ex-husband was just trying to make trouble for his ex-wife and her new boyfriend. You would certainly not want anyone to have reported you or created problems regarding your own children. You remember how often your 5-year-old bruised himself when he was that age. You go about your duties and try to shake off your feeling. What should you do?
A S S I G N M E N T:
1. Solve the case in small groups by using the traditional problem-solving process. Identify the problem and several alternative solutions to solve this ethical dilemma. What should you do and why? What are the risks? How does your value system play a part in your decision?
Justify your solution. After completing this assignment, solve the second part of this assignment below.
2. Assume that this was a real case. Twenty-four hours after the child’s discharge, she is readmitted with critical head trauma. Police reports indicate that the child suffered multiple skull fractures after being thrown up against the wall by her mother’s boyfriend. The child is not expected to live. Does knowing the outcome change how you would have solved the case?
Does the outcome influence how you feel about the quality of your group’s problem solving?
Kearney and Penque (2012) provide another example of a theory–practice–ethics gap in their suggestion that although nurses recognize that checklists can reduce episodes of patient harm by ensuring that procedures are being carried out appropriately, that some providers will indicate that an intervention has been undertaken when it has not. This occurs because of the mantra “If it wasn’t documented, it wasn’t done” and an
increasing emphasis and reliance on documentation that demands that “all boxes must be ticked” to ensure complete care has been provided. Kearney and Penque suggest then that checklists present a context for ethical decision making in that when providers do not take ethics into account, checklists could actually perpetuate rather than prevent unsafe practices or errors.
The Traditional Problem-Solving Process
Although not recognized specifically as an ethical problem-solving model, one of the oldest and most frequently used tools for problem solving is the traditional problem-solving process. This process, which is discussed in Chapter 1, consists of seven steps, with the actual decision being made at step 5 (review the seven steps under “Traditional Problem-Solving Process” section in Chapter 1). Although many individuals use at least some of these steps in their decision making, they frequently fail to generate an adequate number of alternatives or to evaluate the results—two essential steps in the process.
The Nursing Process
Another problem-solving model not specifically designed for ethical analysis but appropriate for it is the nursing process. Most nurses are aware of the nursing process and the cyclic nature of its components of assessment, diagnosis, planning, implementation, and evaluation (see Fig. 1.2). However, most nurses do not recognize its use as a decision-making tool. The cyclic nature of the process allows for feedback to occur at any step. It also allows the cycle to repeat until adequate information is gathered to make a decision. It does not, however, require clear problem identification. Learning Exercise 4.5 shows how the nursing process
might be used as an ethical decision-making tool.
LEARNING EXERCISE
4.5
One Applicant Too Many
T
he reorganization of the public health agency has resulted in the creation of a new position ofcommunity health liaison. A job description has been written, and the job opening has been posted. As the Chief Nursing Executive of this agency, it will be your responsibility to select the best person for the position. Because you are aware that all hiring decisions have some subjectivity, you want to eliminate as much personal bias as possible. Two people have applied for the position; one of them is a close personal friend.
Analysis
Assess: As the Chief Nursing Executive, you have a responsibility to make personnel decisions as
objectively as you can. This means that the hiring decision should be based solely on which employee is best qualified for the position. You do recognize, however, that there may be a personal cost in terms of the friendship.
Diagnose: You diagnose this problem as a potential intrapersonal conflict between your obligation to your friend and your obligation to your employer.
Plan: You must plan how you are going to collect your data. The tools you have selected are applications, resumés, references, and personal interviews.
Implement: Both applicants are contacted and asked to submit resumés and three letters of reference from recent employers. In addition, both are scheduled for structured formal interviews with you and two of the board members of the agency. Although the board members will provide feedback, you have been reserved the right to make the final hiring decision.
Evaluate: As a result of your plan, you have discovered that both candidates meet the minimal job requirements. One candidate, however, clearly has higher level communication skills, and the other candidate (your friend) has more experience in public health and is more knowledgeable regarding the resources in your community. Both employees have complied with the request to submit resumés and letters of reference; they are of similar quality.
Assess:Your assessment of the situation is that you need more information to make the best possible decision. You must assess whether strong communication skills or public health experience and familiarity with the community would be more valuable in this position.
Plan:You plan how you can gather more information about what the employee will be doing in this newly created position.
Diagnose: If the job description is inadequate in providing this information, it may be necessary to gather information from other public health agencies with a similar job classification.
Evaluate: You now believe that excellent communication skills are essential for the job. The candidate who had these skills has an acceptable level of public health experience and seems motivated to learn more about the community and its resources. This means that your friend will not receive the job.
Assess: Now you must assess whether a good decision has been made.
Plan: You plan to evaluate your decision in 6 months, basing your criteria on the established job description.
Implement: You are unable to implement your plan because this employee resigns unexpectedly 4 months after she takes the position. Your friend is now working in a similar capacity in another state. Although you correspond infrequently, the relationship has changed as a result of your decision.
Evaluate: Did you make a good decision? This decision was based on a carefully thought-out process, which included adequate data gathering and a weighing of alternatives. Variables beyond your control resulted in the employee’s resignation, and there was no apparent reason for you to suspect that this would happen. The decision to exclude or minimize personal bias was a conscious one, and you were
aware of the possible ramifications of this choice. The decision making appears to have been appropriate.
The Moral Decision-Making Model
Crisham (1985) developed a model for ethical decision making incorporating the nursing process and principles of biomedical ethics. This model is especially useful in clarifying ethical problems that result from conflicting obligations. This model is represented by the mnemonic MORAL as shown in Display 4.5.
Learning Exercise 4.6 demonstrates the MORAL modeling in solving an ethical issue.